Today, Tomorrow, Together
Quality Account 2012/13
stclarehospice.org.uk Registered Charity No. 1063631
St Clare Hospice Quality Account 2012/13
“I can’t express how grateful I am to have had help to guide me over the last few months. I have learned a great deal and now know I have the strength to carry on forward. I could never have known how much this has helped me and I will be eternally grateful for the service which has been provided out of love.”
“The nurses were as kind to me as they were to my relative - we could not have been in a better environment. The staff wanted to hear what my life had been about. They made me feel I was important.”
St Clare Hospice patients 2012
“You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but also to live until you die.�
Dame Cicely Saunders
Contents
Part 1
Statement on Quality from the Chief Executive Officer…………………………………2 Statement on Quality from the Board of Trustees……………………………………….4
Part 2
Priorities for Improvement 2013/14……………………………………………………......6 Priorities for Improvement during 2012/13….…………………………………………..19
Participation in Clinical Audits…………………………………………………………....27 Participation in Clinical Research..............................................................................27 CQUIN Framework....................................................................................................27 Registration with the Care Quality Commission........................................................27 Data Quality, Information Governance Toolkit ..........................................................28
Part 3
Review of Quality Performance…………………………………………………………..29 Complaints, Compliments and Safety Information.…………………………………….35 Local Audits…………………………………………………………………………………37 Statements from External Stakeholders…………………………………………………49 How to Provide Feedback…………………………………………………………….......50
Part 1: Statement on Quality
Chief Executive Officer Statement
I am delighted to present this Quality Account for St Clare Hospice. As an organisation we are continually striving to ensure we provide quality driven and individualised services to the community of West Essex and the borders of East Hertfordshire. Quality is at the forefront of all we do here, in every aspect of our operational and strategic work.
Over the past year we have worked tirelessly to ensure our clinical contracts and methods of data collection are robust. As an organisation it is vital that we deliver excellent services, which are quality driven yet efficient and effective.
We have been building upon our solid foundations over the past year and have an approach that is forward thinking, responsive and flexible to the ever changing national and local health care landscape, and most importantly meets the needs of patients and families.
We also recognise that in order to deliver the best quality services we wish to work collaboratively with others, sharing knowledge, experience and resources for the benefit of local people.
It has been inspiring to see the growth and development of our services over the past 12 months. How clinical and non clinical teams have risen to the many challenges we have met along the way. It is wonderful to see that every member of staff recognises the important part they play in delivering patient care.
St Clare has always taken pride in its team approach, this has grown and developed over the past year coupled with an open culture and desire to deliver excellence in all we do, we seem to have a combination that will take the organistaion through to an exciting future.
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The year ended with the launch of our vision, mission, values and our five year strategy. Following two years of incredibly hard work we have coordinated every aspect of our Hospice work, centered it around the patient and presented our future vision. This Quality Account is a product of a team’s hard work, their commitment in delivering quality care and developing services with the people they care for. I am pleased to present this Quality Account for 2012/13 and to the best of my knowledge the information contained therein is accurate.
Tanya Curry Chief Executive
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Chairman of the Board of Trustees Statement
During the course of this year, I’m delighted to report that St Clare has really started to gather momentum and pace in developing services for people living in West Essex and East Hertfordshire.
The growth of the Hospice is wonderful to see, as we start to implement our 5 year strategy which has been developed this year with the input of our staff and supported by our user involvement forum.
Supporting families during a most critical time of their life will always be our focus; ensuring excellent patient experience and providing a choice for patients of where they wish to be cared for – be it here at the Hospice or in their own homes.
A key step this year for us was formally adopting the Community Specialist Palliative Care nurses, providing high quality care under the St Clare Hospice banner.
The past year has been about ensuring our foundations are sound and consolidating our senior management team. We have continued to build on our governance structures and quality this year, which I believe is demonstrated throughout the course of this Quality Account.
As Trustees we wish to ensure that the Hospice operates in a safe and professional manner in all areas of its work.
We have fostered an open culture of continually learning and improving our services with shortfalls being identified and acted upon quickly.
We actively seek feedback from all people using our services as well as from our volunteers and our partners in the local community.
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This enables us to use the information positively to learn, develop and improve the quality of all that St Clare does.
As Chairman of the Board I am pleased to support this Quality Account.
Michael Chapman D.L Chairman
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Part 2 - Priorities for improvement
Introduction
This Quality Account demonstrates that St Clare is committed to delivering skilled and compassionate specialist palliative care for our local community. It also reflects our vision to ensure that people with life limiting illnesses have timely access to skilled compassionate and sensitive care. We will support patients and their families to maintain dignity and quality of life by providing exceptional care in a place of their choice. As a centre of excellence we will continue to lead in the development of specialist palliative care services for the population of West Essex and East Hertfordshire.
Our values are fundamental to the delivery of specialist palliative care and underpin everything we do:
Care: We treat patients and families the way we want to be treated – with kindness, compassion and respect Teamwork: We value the unique contribution that all our staff and volunteers make in the delivery of excellent care for our local community Quality: We are passionate in our pursuit of excellence and dedicate ourselves to achieving the highest standard in all aspects of our work Integrity: We are honest and ethical in everything we do and accept the responsibility for the trust placed in us
The priorities for quality improvement identified for 2013/14 are set out below and impact directly on each of the three domains of quality; patient safety, clinical effectiveness and patient experience.
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Priorities for improvement - 2013/14 Future Improvement Priority 1: To improve and develop our existing clinical services, maximising their reach and quality
a) Community Development Quality Domain: Clinical Effectiveness and Patient Experience
Over the past year, community development has been a particular focus for service development and during 2013/14 this will continue to be an area of priority for quality improvement.
Our aim is to develop a community service with the capacity and flexibly to meet individual needs in a timely manner.
A new model of care has been developed to deliver a 7 day Community Palliative Care Service (CPCS) in the community setting with a hands-on care model of Hospice at Home to support patients and families in a time of social crisis or to facilitate end of life care in their place of choice. The service will deliver 3 Key elements: Specialist Palliative Community Service 7 days a week Hospice at Home Pilot (Multi Visit Planned Personal Care and Support) 7/7 St Clare Hospice Friends (befriending service delivered by volunteers)
How was this priority identified?
Through the requirements of the End of Life Care (EoLC) strategy for Specialist Palliative Care (SPC) services to operate over 7 days. The demand for the service to operate over 7 days has been established through a pilot that was undertaken during 2011/12.
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Our Preferred Priorities for Care (PPC) information is indicating that more patients are choosing home as their PPC, therefore there is a need for increased support in the community to enable patients to remain at home during a time of crisis or at the end of life.
A Hospice at Home service will also support compliance with National Insititue for Clinical Excellence (NICE) guidelines; support people approaching the end of life who experience a crisis at any time of day or night receive prompt, safe and effective urgent care appropriate to their needs and preferences.
It has also been identified locally through The Marie Curie, Delivering Choice Programme (2011) that the following core principles support with Quality, Innovation Productivity and Prevention (QIPP) work stream to deliver its quality and efficiency commitments in relation to EoLC. How will this be achieved? 2 business cases have been presented to the West Essex Clinical Commissioning Group We are aiming for the Community Palliative Care Team (CPCT) to be operating over 7 days and; To have started a pilot for Hospice at Home during this year Recruitment of the staff and volunteers Volunteer training and induction programme Staff training programme Operational processes and policies
How will progress be monitored? A project implementation group will be established that will report into the CCG EoLC Group Records of achievement PPC Service evaluation questionnaires from patients and families
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b) Development of a Patient and Family Support Service Quality Domain: Clinical Effectiveness and Patient Experience We are prioritising the development of a Patient and Family Support Service in line with our Hospice strategy. Our aim is to provide counselling services over 7 days and during the evenings and to increase the numbers of volunteers to run and support bereavement groups. There is also a need to develop our pre bereavement input to support patients and their families to prepare them emotionally and practically for end of life or loss of a loved one. During this year we are aiming to recruit to a Patient and Family Support Services Manager and to undertake an in depth review into the current service. How was this priority identified?
A vacancy within the service provided us with an opportunity to undertake an initial review. The review established a need for the service to increase its capacity to provide more support in relation to pre bereavement care. The service currently focuses on adults and the Hospice strategy promotes a need to respond to making the service more widely accessible to families and children.
There is also a requirement to comply with NICE guidelines; to support people approaching the end of life are offered timely personalised support for their social, practical and emotional needs, which is appropriate to their preferences, and maximises independence and social participation for as long as possible.
To enable us to take this service forward in line with the service developments that have been identified, we have prioritised the need to recruit to a Patient and Family Support Services Manager during the first year of developing this service.
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How will this be achieved?
This will be achieved by:
Recruiting to Patient Family Support Services Manager Undertaking a comprehensive review of the service Development of quality markers in line with NICE guidelines
How will progress be monitored?
We have established a Bereavement Services Steering Group that will be reestablished as the Patient and Family Support Services Group when the manager of the service is appointed. This group will include our volunteer manager, bereavement counsellor and social worker. This group will report into the CGC and provide quarterly updates on the progress of the review of the service.
Future Improvement Priority 2: To implement further elements of The End of Life Care Strategy
Quality Domain: Clinical Effectiveness, Patient Experience and Patient Safety In 2013/14 St Clare Hospice will continue to prioritise the implementation of the Department of Health’s End of Life Care Strategy, promoting high quality care for all adults at the end of life. Our quality markers have also been influenced by local commissioning priorities in line with the EoLC strategy and QIPP and the priorities in this section are part of our Commissioning for Quality and Innovation (CQUIN) programme .
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2a) Advance Care Planning (CQUIN) Advance care planning (ACP) is a voluntary process of discussion and review with the aim of helping someone who has the capacity to indicate what their preferences and wishes are for future care If the individual wishes they can record choices about their care and treatment and an Advance Decision to refuse a treatment in specific circumstances. These choices can then be referred to by those responsible for care and treatment if, as the illness progresses, the individual loses capacity to make decisions for themselves (EoLC Strategy, DH 4th Annual Report, 2011)
How was this priority identified?
The EoLC Strategy and local commissioning priorities that were identified through the QIPP work stream to support delivery of the Gold Standards Framework (GSF). This has also been identified as a CQUIN for 2013/14 as a whole health economy measure to ensure all providers are engaged in delivering ACP. The EoLC CQUIN is designed to increase staff confidence and knowledge in ACP via targeted training as a driver to increasing the use of ACP - leading to more patients dying in line with their wishes.
How will this be achieved? Collaborative adoption of ACP document with South Essex Partnership University NHS Foundation Trust (SEPT) and Princess Alexandra Hospital (PAH) Training of all staff in the hospice on ACP Support with training of other staff within other provider organisations Implement in the Hospice setting in Day Therapy Data collection on quarterly basis with key milestones
How will this be monitored? Quarterly commissioning review meetings to monitor achievement of the milestones. Review of the data in clinical governance working group and committee.
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2b) Improve referral rates of Non Cancer Patients (CQUIN)
How was this priority identified? Strategic priority to respond to non-cancer diagnosed patients in response to Hertfordshire Clinical Commissioning Scrutiny (awareness raising) and CCG strategic plans and therefore this has been identified as a CQUIN for 2013/14. This priority is also in line with our Hospice Strategy and our Mission, Vision and Values.
How will this be achieved? To promote accessibility for non-cancer patients in Hertfordshire linking with GPs in the area Promote information on website Link with the EOLC GP Champion
How will this be monitored? Referral data quarterly Quarterly commissioning review meetings and through review of the data in clinical governance working group and committee.
2c) Friends and Family Test (CQUIN) The Friends and Family Test will provide timely and granular feedback from patients about their experience. To improve the experience of patients in line with domain 4 of the NHS Outcomes Framework (CQUIN 13/14 Guidance, NHS Commissioning Board)
There is a question added to the patient survey asking if they would recommend our services to a friend or family. This priority is also in line with our Mission, Vision and Values.
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How was this priority identified? The EoLC Strategy and local commissioning priorities that were identified through the QIPP work stream.
How will this be achieved? Patient Surveys Quarterly milestones to ultimately achieve full delivery of friends and family test achieving a minimum of 15% of all possible respondents and evidence of provider review of the outcome scores with an action plan, if needed, to achieve improvement in service provision
How will this be monitored? This will be monitored quarterly through identifying the number of respondents. Quarterly commissioning review meetings and through review of the data in clinical governance working group and committee. The information will also be reviewed by the User Involvement Forum.
2d) Safety Thermometer The Safety Thermometer is a monthly survey that provides a snapshot of the numbers of harms that are avoidable within in patient care. The harms are measured per patient and identify whether there are links between falls and urinary tract infections. The percentage of harm free care that is calculated in an indicator of whether care provision is safe. The following three avoidable harms that are measured on the NHS Safety Thermometer are; pressure ulcers, falls and urinary tract infections in patients with a catheter. The aim is to increase the proportion of patients receiving harm free care by reducing the prevalence of pressure ulcers, and the proportion of patients with harm from a fall, and patients with urinary tract infections in care using Quarter 1 as a baseline of activity. This tool is widely used within NHS settings and this year will give us an opportunity to review its use and appropriateness within a hospice setting. Improvements will be to year end and to achieve CQUIN will be a 50% improvement in new pressure ulcers in bed based units and community teams and 20% improvement in falls with harm in bed based units subject to exclusion of patients with clinical conditions that predispose them to fractures. (CQUIN 13/14 Guidance, NHS Commissioning Board) 13
How was this priority identified? National CQUIN and local East Hertfordshire Commissioning Priority. This measure is also in line with our patient safety goals and quality markers that we review within our in patient unit. How will this be achieved? Monthly In Patient Surveys based on the set reporting framework Submit data quarterly Baseline to be established in % of harm free care Evidence of consistent reporting and improvements made and maintained at a better rate than the baseline Reporting of patient safety incidents by staff How will this be monitored? Quarterly commissioning review meetings to monitor achievement of the milestones. Review of the data in clinical governance working group and committee.
Future Improvement Priority 3: Adoption of the Support Team Assessment Schedule (STAS) Quality Domain: Clinical Effectiveness and Patient Experience St Clare Hospice has chosen to address symptom assessment as a priority for 2013/14 as inadequate assessments are fundamental barriers in the quality of care at the end of life.
The Support Team Assessment Schedule (STAS) is an outcome measure that assesses quality of care in palliative care patients. STAS is a popular measure and has been used extensively in the UK, across Europe, Canada, the USA, Australia, Asia and Africa. It has been used in a variety of settings, including home care, hospital, in the community, hospice, day care and general practice.
The STAS tool has 9 core or up to 20 optional items covering physical, psychosocial, spiritual, communication, planning, family concerns and service aspects. The problem and need for improvement is scored on a 5 point (0� 4) scale at first contact,
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then regularly thereafter; high scores indicate many problems, low scores few problems.
Our aim is to improve symptom assessment in both malignant and non-malignant disease by the integration of the STAS tool into our clinical documentation and decision making processes.
How was this priority identified? There is a common theme that has been identified through the audit process for a need to improve on the consistency in the quality of assessment and documentation of symptoms. The STAS tool will allow us to monitor the progress of care for individual patients throughout the course of their involvement with the Hospice services, and audit the various aspects of care identified
How will this be achieved? Inclusion of the STAS tool into the staff education programme Record of education sessions attended and delivered by St Clare Hospice staff on the STAS tool Documentation audit of the use of STAS in the Hospice holistic notes Documentation audit of the use of STAS as part of the Hospice MDT meeting Documentation audit of individual problems identified by the STAS tool
How will this be monitored? The implementation of the STAS tool will be lead by the Deputy Medical Director, and progress will be monitored through the Clinical Governance Working Group.
Future Improvement Priority 4: Data Quality Improvement
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Quality Domain: Patient Safety, Clinical Effectiveness and Patient Experience Our aim is to collect and measure data to demonstrate the breadth and quality of our services and to support that we are the provider of choice, delivering quality yet cost effective services We will continue to publish our quality performance within our quality accounts but our staff will be provided within information on a quarterly basis. Within our clinical governance working group and through we will identify themes and trends and also learn from incident reviews and complaints.
How was this priority identified? Delivering high quality care services means that we should capture and understand information about our current level of quality performance and use this to make changes to improve care or disseminate best practice.
We have a plethora of quality metrics to collect and analyse which were identified either through: EoLC strategy NICE guidance Care Quality Commission (CQC) Clinical guidelines Quality improvement (identified through learning from incidents or through the audit process) Local commissioning priorities from West Essex or East Herts CCG (in the form of Key Performance Indicators (KPI’s) or CQUINs Hospice strategy
How will this priority be achieved?
The following table indicates the following measures that we will be reviewing our quality performance against:
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QUALITY AND SAFETY Patient Safety
Safeguarding Vulnerable Adults
Infection Prevention and Control
MEASURE
TARGET
Type
Reduction in the number of high risk medication errors Numbers of falls Numbers of pressure ulcers attributable and avoidable Serious Incidents Implementation of patient safety alerts within deadline Medicines management assessments
<10
KPI
<35 Zero
KPI KPI
Zero 100%
KPI CQC requirement
All patients to be assessed and documentation completed Manchester Patient To achieve Safety Framework generative status to continue to build on (MaPSaF) a positive patient safety culture 95% harm free care Safety Thermometer CQC outcome 2 Compliance with and 7 standards 100% Numbers of staff trained in Mental Capacity Act (MCA) and Safeguarding of Vulnerable Adults (SoVA) Numbers of MRSA Zero Bacteraemia attributable to St Clare Zero Numbers of Clostridium Diffifficile attributable to St Clare Numbers of clinical 100% staff trained in hand hygiene
Quality improvement
Quality improvement
CQUIN CQC CQC
KPI
KPI
Quality improvement; essential steps
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Patient Experience
Care and Compassion
Clinical Effectiveness
and the hygiene code Numbers of staff 100% Quality trained in infection improvement; prevention and essential steps control and the hygiene code Advance Care Baseline Q1, target CQUIN/EoLC Planning (ACP) to be set strategy Number of Complaints regarding patient care Friends and Family Test Advanced communication training Preferred Priorities for Care (PPC) Cancer Dyspnoea Scale (CDS) Liverpool Care Pathway (LCP)
Productivity
Cardiopulmonary Resuscitation (CPR) status recorded in notes Attendance at Gold Standard Framework (GSF) Meetings in Primary Care Length of Stay In Patient Unit Bed Occupancy
To be open and identify themes and trends for improvement Baseline Q1, target to be set All staff to be trained
Contract KPI
Attendance by SPCT at GSF monthly meetings
EoLC Strategy and contract KPI
10 days or less
Contract KPI
>80%
Contract KPI
CQUIN/hospice values EoLC strategy/quality improvement PPC identified and Contract achieved where KPI/quality possible improvement EoLC strategy Numbers completed/outcomes audited EoLC strategy Symptom management achieved Focus in day Quality therapy and hospice improvement wide audit
These measures will be obtained and/or delivered by:
Data collection Incident reporting
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Audit process Patient Surveys Training sessions Quarterly workshops with staff Root cause analysis (RCA)
How will this priority be monitored?
All information will be monitored by the clinical governance working group (CGWG ) and the clinical contract KPI’s and CQUINs will also be monitored though commissioning reports and quarterly review meetings.
Priorities for Improvement during 2012/13
The aim of the Quality Account is to not only set future priority improvements but to also evidence achievements on priorities for improvement from the previous year. In last year’s report we set out 3 priorities for improvements for out services. All areas identified were specifically selected as their would impact directly on the care of our patients and families received, either through improvement patient safety, clinical effectiveness or the patient’s experience.
The quality improvements for 2012/13 were: Priority 1: Develop the Hospice at Home service Quality Domain: Clinical Effectiveness and Patient Experience Standard •
To review weekend admissions and determine what impact the new service has on admission avoidance
•
Audit whether the Preferred Priorities of Care documentation is completed for patients seen by our Community Specialist Palliative Care Team (CSPCT).
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•
During 2012 St Clare Hospice undertook a pilot for the Community Specialist Palliative Care Service to work 7 days per week which demonstrated the demand to support patients at home.
•
Data was recorded for the 12 weeks of the pilot, based on weekend and bank holiday figures between May 2012 and July 2012; it was established that 10 hospital admissions were avoided due to the specialist assessment and management of symptoms.
•
The team are not currently resourced to operate over 7 days, a business case has been written and submitted to the CCG requesting 1.08 wte additional SPCNs to increase capacity within the service and also to enable the development of the Hospice at Home Service.
•
PPC assessments are demonstrating that an increasing number of patients are expressing a wish to die at home
Service status
Dates 01/02/2010 Pre SPCT 31/01/2011 1st year 01/02/2011 SPCT 31/01/2012 01/02/2012 2nd year SPCT 31/01/2013
Indicated PPC Hospice
Indicated PPC Home
Indicated PPC % Hospice
Indicated PPC % Home
64
50
56%
44%
50
105
32%
68%
77
147
34%
66%
Priority 2: Review and Implement further elements of The End of Life Care Strategy
Quality Domain: Clinical Effectiveness, Patient Experience and Patient Safety
Standard 2a: To attend and support the benefits of attending Gold Standard Framework Meetings
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We are fully engaged in the Quality, Innovation, Productivity and Prevention Work stream to improve the proportion of people who die in their usual place of residence.
The SPCNs attended more than 97 GSF meetings over the past year where the SPCNs and the Medical Director provide leadership, support, education, and information and to collaborate with all providers to ensure a consistent approach to palliative care for the local population. The measurement of the GSF After Death Analysis is being measured within the Older Peopleâ&#x20AC;&#x2122;s Programme Board at West Essex CCG that we attend on a bi monthly basis.
Preferred Priorities for Care (PPC) and the Liverpool Care Pathway (LCP) are embedded within clinical practice which is demonstrated in measures 2b and 2c. Priority 2b: Review and Implement further elements of The End of Life Care Strategy
Quality Domain: Clinical Effectiveness, Patient Experience and Patient Safety Standard 2b: To reflect on the use of the Liverpool Pathway LCP in clinical practice
Documentation audit
The Liverpool Care Pathway (LCP) is a national tool to improve end-of-life care by transferring the hospice model of care into other settings. Outcome measures relating to the physical, psychological and spiritual comfort of the patient are routinely audited during implementation.
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We completed a retrospective documentation audit of our holistic notes to ascertain whether or not the LCP was being used and if so how was it applied.
The results
showed that:
92% of patients whose death was expected were commenced on the LCP In Section 1 advanced care planning was not completed in any patient perhaps due to these areas being documented elsewhere Section 2 showed the greatest compliance with 84% of the document completed Section 3 communication of death showed the least compliance The implications for our clinical practice following this audit:
There are still areas of our clinical practice to develop, in particular sections 1 and 3, although duplication may account for some lack of documentation in section 1 the current processes informing other health care professionals about the patientâ&#x20AC;&#x2122;s death is not being documented in section 3.
This is partly explained by information being recorded in other areas of the notes by administrative staff.
Given the audit and the recent media coverage on the LCP and update education session on LCP at the next staff education session was planned
Avoid duplication when the holistic notes are revised later this year To audit other areas of the notes in order to ensure that the patientâ&#x20AC;&#x2122;s death is communicated and documented
To include education session on care in bereavement at the next staff education session
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Healthcare professional survey A six-item questionnaire survey presented to healthcare professionals working within specialist palliative care was undertaken to determine their views regarding the LCP and whether they felt further training points were required.
14 questionnaires were sent out and 14 were returned.
In summary: 11 agreed the LCP represents best practice care for the dying person 13 felt confident assessing when a patient should be started on the LCP 9 felt confident discussing the process of implementing the LCP with patients 10 felt confident discussing the process of implementing the LCP with families 10 would want the LCP used for them or their family 5 required further training on the use of the LCP The result of the survey will be used to inform our on-going education programme
Education sessions There has been much media interest around the use of the LCP. Published misconceptions and often inaccurate information about the Liverpool Care Pathway risk detracting from the substantial benefits it can bring to people who are dying and to their families. At St Clare Hospice we support the appropriate use of LCP and make clear that it is not in any way about ending life, but rather about supporting the delivery of excellent end of life care. Education sessions are important in supporting our practice and have been planned in collaboration with SEPT as part of a collaborative advanced care planning initiatives. Given the planning process the sessions were postponed until May 2013 and completed at the time of writing this report
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Priority 2c: Review and Implement further elements of The End of Life Care Strategy
Quality Domain: Clinical Effectiveness, Patient Experience and Patient Safety Standard 2c: To reflect on the use of the Preferred Priorities for Care (PPC) in clinical practice
Documentation audit We completed a retrospective documentation audit of our holistic notes to ascertain whether or not the patient PPC was recorded. In summary: 36 notes were reviewed. A PPC was documented in 32 (89%) instances. In most cases (75%) the PPC was documented. In 20 (56%) patients the PPC was documented on the care database. The audit demonstrates that further work is required to ensure all patients have the opportunity to express a PPC, and staff will receive education on the use of PPC and procedural changes will be made to our computerised patient record system to ensure the information can be recorded accurately Documentation audit of the MDT meeting’s information sheet showed that 47% of patients’ PPCs were documented in the communication sheet of our multiprofessional notes. Given the increased public awareness sessions of the PPC, an education programme has been planned in collaboration with SEPT to be delivered in May 2013 as part of the future Dying Matter campaign. Holistic notes audit We completed a retrospective documentation audit of our holistic notes and computerised patient record system to ascertain whether the patient’s place of death (PPD) was the same as their PPC.
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23 sets of notes were reviewed The PPC was documented in 15 (65%) sets of notes In 9 (60%) patients PPD was the same as PPC. The audit demonstrates that further work is required to ensure all patients have the opportunity to express their PPC. It would also be helpful to explore further why the PPD and PPC are often different and whether patients are stating where they wish to die when they are expressing their PPC; the PPC document does not specifically ask where the patient wishes to die. Education sessions Education sessions that have been planned alongside the advanced care planning initiatives in collaboration with SEPT, have been postponed until May 2013 and will be completed at the time of writing this report
Priority 3: Development of Management of Breathlessness
Quality Domain: Clinical Effectiveness and Patient Experience Standard: To improve the assessment and management of breathlessness in both malignant and non malignant disease through the evaluation of breathlessness intervention clinic (BIC) by using the Cancer Dysponea Scale (CDS) before and after intervention.
Interventions at Breathlessness Intervention Clinic (BIC) were evaluated using the CDS for patients with cancer and non-cancer diagnosis.
23 patients (14 females, 9 males) were seen at BIC, where they had complex interventions at Breathlessness group over a period of 12 months. They routinely recorded the severity of their breathlessness on CDS (measuring Effort 20 + Anxiety 16 + Discomfort 12 = Maximum 48). Their particulars were recorded from their notes. Patients were asked a questionnaire to record their assessment of CDS for user-friendliness. CDS was repeated after the intervention completed in 12 weeks.
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Analysis and Results The mean age was 76 years (50 – 91). 12 patients had advanced Chronic Obstructive Pulmonary Disease (COPD), whereas 1 had Cardiac failure and 2 each had pulmonary fibrosis and cancer. Before intervention, a mean of 19.7 (3 – 35) score was calculated at CDS (Effort 9.4, Anxiety 5.9 and Discomfort 4.2). All patients were admitted to BIC. 19 patients completed the programme (2 died, 2 unable). After intervention, a mean of 10.8 was calculated (Effort 5.1, Anxiety 2.8 and Discomfort 2.9). 3 patients showed worsening of scores whereas 16 patients showed improvement. We concluded that BIC is a useful method as it improves patients’ quality of life with malignant and non-malignant diseases while objectively measured with CDS. Review of services During 2012/13 St Clare Hospice provided five services for adults partly-funded by the NHS. The services were: •
Inpatient Unit
•
Day Therapy
•
Outpatients
•
Community
services
–
St
Clare
Community
Specialist
Nurses,
Physiotherapists, Occupational Therapists and Social work / Psychological services •
Bereavement support
St Clare Hospice has reviewed all the data available to them on the quality of care in all of these services. The income received from the NHS in 2012/13 represented 30% of the total cost of running our services.
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Participation in Clinical Audits
During 2012/13 St Clare Hospice was not eligible to participate in any national clinical audits or national confidential enquiries and therefore there is no information to submit. This is because none of the 2012/13 audits or enquiries related to specialist palliative care.
Participation in Clinical Research
The number of patients receiving NHS services provided by St Clare Hospice that were recruited during that period to participate in research approved by a research ethics committee was 0. During 2012/13 there were no appropriate national, ethically approved, research studies in palliative care in which we could participate.
Use of CQUIN payment framework
St Clare Hospice income during 2012/13 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework. Registrations with the Care Quality Commission (CQC)
St Clare has no conditions attached to registration and the Care Quality Commission has not taken any enforcement action during 2012/13. Data Quality and your actions to improve Data Quality
St Clare Hospice will be taking the following actions to improve data quality: During 2012/13 the policy and procedure to ensure standardised reporting for compliments and complaints has been revised, with staff training to support with implementation. Complaints are shared at the risk meeting and reported to Clinical Governance Committee if any themes and trends are identified.
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Processes have been reviewed and a new policy and procedure is now in place to standardise our approach.
Minimum Data set is compared with historical data to monitor changes in services and also reviewed within commissioner review meetings.
All clinical data; performance and quality are collated, analysed and verified with clinical managers and the clinical governance committee.
Information from informal audits and surveys are reviewed in CGWG to monitor and improve services. Information Governance Toolkit
St Clare Hospice has registered to use the Information Governance (IG) Toolkit but at this time it has not been used to assess information governance management. During 2012/13 we reviewed our processes and policies and procedures are in place. All staff received IG training. We have a Caldecott Guardian. We did not have any breaches of confidentiality or any Freedom of Information requests.
Clinical coding error rate St Clare Hospice was not subject to the Payment by Results clinical coding audit during 2012/13 by the Audit Commission
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Part 3 - Review of Quality Performance The figures below provide information on the activity and outcomes of care for patients in 2011/12 and 2012/13 compared to the median for other Hospices prepared by the National Council for Palliative Care (NCPC).
The National Council for Palliative Care: Minimum Data Sets for 2011/12 and 2012/13 St Clare Total number of patients 2012/13
St Clare Total number of patients 2011/12
National median 2011/12
National min. 2011/12
National max. 2011/12
1,359
1585*
1791
1209
3536
*
The figure for last year was higher due to the transfer of the community caseload .
The National Council for Palliative Care: Minimum Data Sets for Inpatient Units 2011/12 and 2012/13 St Clare Hospice has been identified as a small unit (fewer than 10 beds); there are 26 units included in this category. All Service Users
Total patients New patients % Number rereferred
St Clare 2012/13
St Clare 2011/12
National median 2011/12
National min 2011/12
National max 2011/12
205
203
132
19
208
94.1
92.1
90.7
67.5
97.0
5
8
8
0
57
29
Diagnosis
St Clare 2012/13
St Clare 2011/12
National median 2011/12
National min 2011/12
National max 2011/12
14.88
3.2
8.3
1.9
28.3
St Clare 2012/13
St Clare 2011/12
National National min median 2011/12 2011/12
National max 2011/12
Available bed day
2920
2928
2242
365
3376
Cancer Avg. length of stay
11.2
9.4
11.8
7.9
23.6
Non Cancer Avg. Length of stay
9.9
10.2
10.1
1.3
16.1
% Occupancy
85.1
78.3
78.9
58.1
100
% Availability
100
100
100
70.3
100
% Non Cancer
Bed Usage
30
The National Council for Palliative Care: Minimum Data Sets for Day Therapy 2011/12 and 2012/13 Day Therapy service at St Clare Hospice has been identified as a medium unit (114-177 patients); there are 47 units included in this category. All Service Users
Total patients New patients % Number rereferred
St Clare 2012/13
St Clare 2011/12
National median 2011/12
National min 2011/12
National max 2011/12
150
145
142
116
176
72.0
70.3
64.1
37.1
89.2
9
16
4
0
23
St Clare 2012/13
St Clare 2011/12
National median 2011/12
National min 2011/12
National max 2011/12
30.5
23.5
16.9
1.3
42.3
Diagnosis
% New Patients Non Cancer
31
The National Council for Palliative Care: Minimum Data Sets for Outpatients 2011/12 and 2012/13 Nationally St Clare Hospice has been compared with units with fewer than 272 patients (50 units). All Service Users
Total patients New patients % Number rereferred
St Clare 2012/13
St Clare 2011/12
National median 2011/12
National min 2011/12
National max 2011/12
156
139
150
91
272
69.23
83.5
62.2
7.1
89.5
8
3
3
0
82
St Clare 2012/13
St Clare 2011/12
National median 2011/12
National min 2011/12
National max 2011/12
61.1
44
13.1
0
80.6
National National median min 2011/12 2011/12
National max 2011/12
Diagnosis
% Non Cancer
Attendances
Number of Clinic Attendances
St Clare 2012/13
St Clare 2011/12
225
190
288
9
5,026
32
The National Council for Palliative Care: Minimum Data Sets for Community Team (Home Care) 2011/12and 2012/13
Nationally St Clare Hospice has been compared with more than 839 patients (11 units). All Service Users
St Clare 2012/13
St Clare 2011/12
National median 2011/12
National min 2011/12
National max 2011/12
Total patients
719
999
1,215
885
2,630
New patients
527
911
911
628
1,735
Number rereferred
83
6
48
6
121
The stats for 2012/13 are lower for total patients and new patients that for 2011/12 because the nurses transferred to St Clare Hospice in that year with approx 400 patients on their caseload that needed to be discharged because they did not need Specialist Palliative Care input. The figures for 2012/13 demonstrate a more accurate picture of the current capacity that is manageable by the team of 3.8 wte and the re referral rates are higher because patients are discharged from the caseload once their symptoms have been controlled effectively. The proportion of patients that were re-referred into the service were likely to need Specialist Palliative Care support at the end of life.
Contact Analysis
Professional Medical consultant Doctor Clinical Nurse Specialist
Face to face follow up
Face to face first
Telephone
14
0
0
0
0
0
431
1846
6950
33
Nurse
0
1
270
104
45
224
Occupational Therapy
36
30
153
Social worker
15
0
698
Spiritual Carer
0
0
0
Psychologist
0
0
0
Complementary Therapist
0
0
0
Other Health Care professional
0
0
0
Physiotherapist
St Clare 2012/13
St Clare 2011/12
National median 2011/12
National min 2011/12
National max 2011/12
48.8
101.3
116.7
40.0
162.0
New non-cancer %
7.5
4.8
14.0
4.8
25.0
% of new patients aged 25 to 64
28.4
32.5
25.0
18.3
32.5
Average length of home care
The average length of home care has reduced because the patients are discharged from the SPCT caseload. The figures are running closer to the national minimum due to a lack of resources in the team and the need to manage the caseload very tightly. The National Council for Palliative Care: Minimum Data Sets for Bereavement Services 2011/12and 2012/13 Nationally St Clare Hospice has been compared with fewer than 250 clients (41 units). All Service Users
Total patients
St Clare 2012/13
St Clare 2011/12
National median 2011/12
National min 2011/12
National max 2011/12
129
99
152
98
250
34
New patients %
65.1
68.7
72.2
34.3
104.1
Number reaccessing
0
3
0
0
10
Contact with service users St Clare 2012/13
St Clare 2011/12
Face to face (by trained and supervised person)
359
293
Face to face â&#x20AC;&#x201C; complex intervention by mental health specialist
88
124
Other Quality Markers we have chosen to measure
In addition to the limited number of suitable quality measures in the national dataset for palliative care, we have chosen to measure our performance against the following indicators that will be measured and reported on during 2013/14
Complaints and Compliments
Complaints 2012/13 Total number of complaints 2012/13: A total of 33 complaints were received (17 related to patient/family care). Any complaints received were fully investigated and appropriate action taken. All complaints were discussed at the Risk Management Group and Root Cause Analysis carried out on two complex complaints, one of which related to a clinical matter. All complaints are shared with the Audit Committee.
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Compliments 2012/13 Compliments are received in a variety of ways at St Clare, including from feedback surveys in the In-Patient Unit, Day Therapy, Bereavement and Community teams, as well as letters.
Here are a selection received in 2012/13:
Day Therapy: “I have felt very fortunate to be part of St Clare – I have been made welcome as if I am family and I have enjoyed it immensely.” Community Team: “I felt really at home as soon as I met (my specialist nurse). She is down to earth practical, helpful as well as sympathetic. My only regret is not contacting earlier.” Bereavement: “I feel so much better after these sessions. Thanks.” IPU: “My relative wanted to spend her last days at St Clare and we can all see now why she wanted that. All the family can never thank you enough.”
Safety Information Accidents/Incidents 2012/13
Accidents
Incidents
Drug Errors
Patient falls
42
15
20
34
Drug related incidents – There were 20 drug related incidents,10 related to administration errors, there were no serious consequences from these incidents. 10 were labelling and stock errors.
Accidents – There were 42 accidents reported 34 of these related to patient falls. No serious injuries incurred.
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Incidents â&#x20AC;&#x201C; 15 were reported with no themes or trends identified
Local Audits
To ensure a high quality of services a variety of audits were undertaken using nationally agreed formats often specifically developed for Hospice care as well as locally developed audit tools. This has enabled us to monitor the quality of services and make improvement where needed. It is planned to develop an annual audit programme to further improve the effectiveness of audit activity.
During 2011/12 St Clare Hospiceâ&#x20AC;&#x2122;s Clinical Governance Working Group reviewed the results of 20 audits. The audits related to a cross section of Hospice activity including the holistic notes (see section on improvement priority 2 for 2011-2012), the inpatient unit, the day therapy service, advice line calls, and assessments by the community palliative care team.
Hospice Audits April 2012 â&#x20AC;&#x201C; March 2013 In-patient Unit Standard
Findings
Action Plan
The Inpatient MDT meeting will be attended by representative of the hospice multiprofessional team
25 meetings took place in the time period audited; nine professional groups are listed in the attendance register: nurses, doctors, occupational therapist, physiotherapist, psychological therapist, clinical nurse specialist, social worker, chaplain, bereavement counsellor. The results showed 70% of PPC audit sheets had been completed and faxed over to the relevant offices required. The other 30% of patients looked at had not completed any PPC documentation so no audit form completed, or sent
To review findings at clinical governance working group
The PPC audit sheets are faxed to the PCT audit office and all other relevant professionals and then filed in the patient notes.
To make sure when PPC audit form completed it is sent to the people involved in that patients care. When the form has been faxed document in notes so everyone knows it has been done. To educate the team on the
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off for these patients.
Each patient readmitted to the hospice will have a new holistic assessment documented in Section 1 of the clinical notes All patients under the care of the hospice will have their and their families expectations of care documented in Section 1 page 17 of the clinical notes
importance of faxing this document, to make sure everyone aware of the patient’s wishes. Each patient re-admitted to the Standard met hospice had a new holistic Continue the current process assessment documented in Section 1 of the clinical notes (100%)
Patient’s expectations were recorded in 9 notes (90%) No reason was given where no expectations were documented Carers were not present on 4 occasions Carers were not asked on 1 occasion – no reason given Carer expectations were 5 notes (83%) All patients under the All patients had relevant care of the hospice will entries in section 2 of the have their plan of care clinical notes reviewed regularly and documented in section 2 (Multi-disciplinary care plan) of the clinical notes The holistic notes Out of the 10 sets of notes signature sheet there was only 1 set of notes contains a record of all where all the people who had MDT members who written in the notes had signed make written entries in the front signature sheet. section 3 of the holistic Out of the other sets of notes it notes. varied from only 1 person who hadn’t signed in a set of notes, up to 4 people who had not signed the sheet in 1 set of notes. The average number of people overall who hadn’t signed the sheet was 3 The patient’s mental 2 patients had the same capacity is number of initials as MC documented at each entries, written entry in section 2 patients had signatures in
Reinforce message to hospice staff To form part to IPU reflection
To continue the handovers and MDT meetings and document the management plan
To check who has written in notes each shift, and check have signed signature sheet, if not to get them to sign when next seen. Educate staff that the signature sheet is part of our holistic notes and needs to be completed by all members of the MDT who have seen a patient, and why it is important to complete it.
To educate team members on the importance of completing the mental capacity column for each entry, to maintain best practice,
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3 of the holistic notes
Patients admitted to the hospice will have their PPC documented, or in the event of patient refusal, documentation that it has been discussed
half the entries, 1 patient had 17 entries, 9 unsigned, 1 patient had 17 entries with unsigned, 1 had 16 entries with unsigned, 1 had 12 entries with unsigned, 1 had 12 entries with unsigned, 1 had 11 entries with unsigned.
8 8 5 7 3
and to be able to see any changes in the patientâ&#x20AC;&#x2122;s condition. Discuss with Social Worker lead for MCA training updates. To tell the team will be reauditing this paperwork in the future, and it is an important piece of information in giving patient care, to encourage them to sign each entry. Remind Staff at handovers and MDT to complete column To check notes at end of each shift to check each entry signed. If an entry missing try to get person to come back and fill in appropriate box. To make sure the PPC documentation is completed for each patient on admission, and if not completed, at least discussed with them, so they know what it is, why we complete it, and how it can benefit them in getting the care they want in the right place when the time comes. To have a teaching session on what the PPC documentation is and ways to approach a patient about it without worrying them
From the results 80% of patients had completed their PPC document, 1 completed it in another hospital, 1 at home and the rest in the hospice. 10% of patients had not filled in documentation, but had been discussed with them. The final 10% had not filled in documentation, and it was not documented whether it had been discussed with them or not. All patients will have 100% of the charts had as Standard met medications needed drugs written up for Continue the current process prescribed on the as each patient. needed section of their drug chart. Following their 70% of the assessments filled Educate the team to make sure assessment, patients in at initial assessment, they are aware how important will have their needs 20% of patients unresponsive, this assessment can be to give identified and 1 on LCP, family assisted with the right care to each patient. documented in the To continue to re-audit to make the other. 10%, holistic notes. 1 patient was asked what sure filling in assessments and goals wanted to achieve, but meeting requirements. the patient didnâ&#x20AC;&#x2122;t feel able to When checking assessments, to check completed on admission, say at time of asking. if not to talk to the patient to
39
The LCP is completed for all hospice inpatients entering the terminal phase of their illness, and filled in appropriately.
The results show only 20% of the LCP documentation was filled out completely. In 30% of patients, page 7 had not been completed. In 50% of patients page 17 had either been partly filled in, or not at all. In 50% of patients the front information sheet had been completed and given to family, the other 50% had not been completed or given to family. Although not all documentation completed, the patients once commenced on the LCP were all in the terminal stage of their illness, and it was appropriate to commence them on the dying pathway All drugs administered 10 (100%) sets of the drug by clinical staff will be charts had prescription signed/accounted for information documented Mandatory risk 9 (90%) sets of the holistic assessment for bowel notes had the bowel care care are completed for assessments completed all patients
A discharge plan will be recorded for all patients to be discharged
There is evidence in section 3 of the holistic notes that families have been involved in
establish their goals whilst at the hospice, and complete assessment. To talk as a team about the patient and see if agree should start LCP. To educate students, new staff, and other team members in what signs to look for to show a patientâ&#x20AC;&#x2122;s condition may be changing. To talk to family before starting LCP and what that means.
Standard met. Continue the current process Inpatient unit staff to be reminded of the importance of completing bowel assessments for all patients The person leading handover meetings must ensure the mandatory assessments are being completed Staff should document in the discharge planning section that patient has no discharge planning needs to fully understand that this element of the patients care has been considered and discussed with the patient
9 (90%) sets of the holistic notes had the discharge planning documentation completed The patient that did not have a discharge planning record was independent on admission and only stayed for one day for an intervention. 10 (100%) of the holistic notes Standard met had documented evidence that Continue the current process families have been involved in the care of the patient
40
discussions about the patients care The medication chart in appendix 1 of the holistic notes will be completed for all patients The Medicines Management Assessment (Appendix 1) has been completed for all patients admitted to Hospice services. Mandatory risk assessment for mouth care are completed for all patients
Mandatory risk assessment for moving and handling are completed for all patients Patient related information on drug charts is legible All patients will have a past medical history documented in their holistic notes (section 1 page 1) Each of the elements on the drug chart prescription are completed The Inpatient MDT meeting will be attended by representative of the hospice multiprofessional team
10 (100%) sets of the holistic Standard met notes had the medication chart Continue the current process completed in the holistic notes.
8 (80%) were not completed
Clinicians caring for patients should be reminded to ensure the Medicines Management Assessment (appendix 1) is completed for all patients in all service areas.
9 (90%) sets of the holistic Inpatient unit staff to be notes had the mouth care reminded of the importance of assessments completed completing mouth care assessment for all patients The person leading handover meetings must ensure the mandatory assessments are being completed 10 (100%) sets of the holistic Standard met notes had the moving and Continue the current process handling assessments completed 10 (100%) of the drug charts had patient information documented 10 (100%) sets of the holistic notes had the past medical history completed in the holistic notes.
Standard met Continue the current process Standard met Continue the current process
10 (100%) sets of the drug Standard met charts had prescription Continue the current process information documented 46 meetings took place in the To review findings at clinical time period audited; 4 governance working group meetings were cancelled. Nine professional groups are listed in the attendance register: nurses, doctors, occupational therapist, physiotherapist, psychological therapist, nurse managers, social worker,
41
All the patients (100%) who attend St. Clare Hospice and report breathlessness must be assessed by using the Cancer Dyspnoea Scale
chaplain, bereavement counsellor. In July Complimentary therapist was added and in August Pharmacist. Break down of attendance Consultant = 11 Deputy Medical Director = 29 Staff grade = 41 SHO = 7 The results obtained showed To educate staff in use of that out of 28 patientâ&#x20AC;&#x2122;s only six Cancer Dyspnoea Scale patients had the cancer dyspnoea scale performed. To reaudit in 6 months time Five of those patients being assessed in patient and one being assessed in the community.
Day Therapy Standard The Day Therapy MDT meeting will be attended by representatives of the hospice multiprofessional team
The Day Therapy MDT meeting will be attended by representatives of the hospice multiprofessional team
Findings Sixteen meetings took place between October 2011 and March 2012; six meeting dates were identified as cancelled Eight professional groups are listed in the attendance register: nurses, doctors, occupational therapist, physiotherapist, psychological therapist, clinical nurse specialists, social worker, chaplain; bereavement counsellor was on the list in October 2011 but not present on the list from November 2011 and therefore excluded from the results Thirty three meetings took place between January 2012 and December 2012; twelve meeting dates were identified as cancelled. Thirteen professional groups or roles are listed in the attendance register: Day Therapy manager, nurses, doctors, occupational therapist,
Action Plan To review findings at clinical governance working group
To review findings at clinical governance working group
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physiotherapist, psychological therapist, social worker, chaplain, bereavement counsellor, community palliative care team manager, IPU manager, Director of patient care, Therapy assistant. Patient goals were documented Management goals will be documented in all 10 sets of notes (100%) following a patients after assessment, representing initial assessment at an improvement on the the end of section previous audit which showed one in the holistic only 80% of patients had goals notes. set after assessment. Management goals 100% of patients had will be documented documentation of an MDT at each Day Therapy discussion at all 3 points during MDT meeting in their Day Therapy admission. section 2 of the This shows an improvement holistic notes. since the previous audit when only 40% of notes met the standard. Treatment plans for The previous audit showed that each patient will be on average treatment plans set during handover were documented for 8.3 days, on the morning that this audit shows some patients are expected improvement with an increase to attend Day to 9.2 days, however the audit Therapy. still failed to meet the standard.
New goals are set for all patients who are re-referred or referred internally to DT when they begin their placement
100% of patients who were rereferred or referred internally for Day therapy had new goals reset. This was an improvement on the last audit where only 20% of patients had their goals re-set.
Practice has improved since last audit. No change to current practice required, continue to maintain good practice.
Practice has improved since last audit. No change to current practice required, continue to maintain good practice.
The audit failed to meet the standard There has been a small improvement since the last audit, however further improvements need to be made. Day Therapy Manager to remind staff of importance of weekly review of patient need & documentation of this. Practice has improved since last audit. No change to current practice required, continue to maintain good practice.
CPCT Standard The Community Palliative Care Team MDT meeting will be
Findings Action Plan Twenty five meetings took place To review findings at clinical between October 2011 and governance working group March 2012; 13 professional
43
attended by representatives of the hospice multiprofessional team
The Community Palliative Care Team will prioritise referral according to very urgent (where possible contact made on day of receipt or next working day) urgent (within two to three working days) and routine (within a week of receipt).
To determine whether Community Palliative Care Team respond to referrals in accordance to the current policy and determine if we have had a significant increase in number of referrals received.
groups are listed in the attendance register and three others (bereavement counsellor, physiotherapist and occupational therapist) added their names when they attended The community team received 129 new referrals and 66 rereferrals. Only the new referrals were audited. Of 129 new referrals 50 were routine, 29 urgent 5 very urgent. On 31 the urgency was not stated and on 14 not recorded. On all referrals patient and or referrer contact was made within times stated on procedure. All very urgent referrals patients were seen/assessed within specified time. 15 of the 29 urgent referrals were seen within time criteria. Reasons for not having assessment within 3 days were patient and CNS agreed visit dates according to need 6, patients in hospital 4, death of the patient 2 and inappropriate urgent referrals referred back to primary care 2. All routine, non stated and not recorded referrals contact made and agreed assessments within specified times. The community team received 159 new referrals of which 64 were routine, 39 urgent 5 very urgent; on 51 the urgency was not stated. Of 108 referrals where urgency stated the standard was met. All routine and non stated referrals contact made within specified times.
Where urgency is not stated on the referral referrer should be contacted to establish explaining our procedure. Accurate recording of referral urgency. Response should be made from CNS not usually working in that geographical area when needed. Re-audit after pilot of seven day working. Educate referrers on procedure.
Where urgency is not stated on the referral, referrer should be contacted to establish explaining our procedure. Internal referral forms to state urgency. Where old referral forms are used referrer to be directed to website for new form. Response should be made from CNS not usually working in that geographical area when the key
44
worker does not have capacity for initial assessment. Draft a policy and procedure for creation of a waiting list for clinical governance. Re-audit after pilot of seven day working creation of policy/procedure. The Community Forty eight meetings took place To review findings at clinical Palliative Care Team between January 2012 and end governance working group MDT meeting will be of December 2012 Three attended by Meetings were cancelled due to representatives of unavailability of core members; the hospice multi11 professional groups are professional team listed in the attendance register. Manager attended 44 Doctors attended 39 CNS team representation at all meetings, DOPC attended 6 (vacant post between April and November 2012) the Chaplain did not attend any. Social worker attended 12, Psychological therapist 7 and bereavement co-ordinator 16 = 33 between the team. Day therapy manager attended 2. Cancer information service did not attend Physiotherapist attended 9 and Occupational therapist 1 DNACPR forms are No DNACPR forms completed. Ensure if discussion has taken completed place regarding advance care planning this is recorded on page 2 of holistic notes Plan opportunities for advanced care planning before death/discharge Discuss use of DNACPR forms for all patients discussed at GSF meetings Share findings with team PPC documents are 2 (20%) PPC documents Ensure if discussion has taken completed completed place regarding advance care planning this is recorded on page 2 of holistic notes Plan opportunities for advanced care planning before
45
Preferred priorities of care are discussed before patients discharged
death/discharge Share findings with team Evidence of PPC discussed in Ensure if discussion has taken three cases = 30% place regarding advance care planning this is recorded on page 2 of holistic notes Plan opportunities for advanced care planning before death/discharge Share findings with team
Hospice wide Standard A hard copy record of all alerts will be maintained in the office of the PA to Director of Patient Care
The Director of Patient Care receives the alerts via e-mail or in their absence will be given to their Deputy.
The date of any relevant action taken must be recorded appropriately
All relevant alerts are acted on within the
Findings 35 Alert notifications were received during this period 4 Alerts were received requiring action/circulation and a hard copy of the relevant alerts and appropriate action are retained Hard copy and electronic copy of the spreadsheet of all alerts received is retained 35 alerts were received during this period 34 alerts were dealt with on the date of receipt 1 alert received immediately prior to extended statutory holiday was not dealt with on the same day 35 Alerts were received 4 Alerts needed to be circulated for information/action and this was done on the date of receipt and recorded on spreadsheet. 3 of these alerts were not signed and dated but e-mail attached to alerts from Director of Patient Care. 1 Alert circulated for information only, note made and dated on original alert. 35 Alerts were received Of the 4 relevant alerts
Action Plan As the alerts now arrive by email amend the policy procedure to reflect that a scanned copy of the relevant alerts will be retained for a period of two years from the date of receipt.
Change the policy procedure to identify the Director of Patient Care as being the designated recipient. Continue with current procedure
Policy procedure should be amended to state that a copy of the e-mail from Director of Patient Care/Deputy circulating information/action must be attached to relevant alerts. Where a member of staff is requested to check a relevant alert a copy of the e-mail response should also be attached to the relevant alert stating the action taken. Add additional information to alerts spreadsheet to record
46
time scale detailed response times are detailed in where time specified for relevant within the alert the following table which shows action and confirm this was 1 was not met. adhered to as appropriate. A copy of the e-mail from the Director of Patient Care or their Deputy circulating the alert must be attached to the alert as verification Details of all alerts 35 alert notifications were Standard met received and action received during this period Continue the current process taken should be 4 alerts required further action recorded on the and they were all recorded database maintained by the PA to the Director of Patient Care All patients under the 8 patients had CPR status To present findings at clinical care of the hospice documented (80%) governance working group and will have a record of Two patients (both day therapy ask for Day therapy input their resuscitation patients did not have any record status documented in of their CPR status the clinical notes
Other Quality Initiatives
Newsletter and website St Clare News is published three times per year for all stakeholders. Along with our website it provides information on our services and celebrates the achievements of all aspects of the Hospice. They also provide an opportunity for patients, carers, staff and volunteers to comment on the work of the Hospice. Internal communication cascades are also in place.
What have carers and users said about St Clare Hospice
User Feedback Questionnaires At St Clare Hospice every service user has the opportunity to provide feedback on their experience of the service. Information is collected using a service questionnaire and then collated. The feedback is shared with staff on a quarterly basis; key themes are highlighted, with an action plan completed. An annual summary is produced and
47
shared with our commissioners. The Hospice team receive all data as well as an annual agreed action plan detailing priorities for improvement. The action plan is a live document, reviewed every quarter to ensure as an organisation we are responsive to feedback and proactive in our work. Displays around the Hospice building showing a summary of feedback received and the action taken were implemented in 2012. These displays will be refreshed and updated quarterly.
Comment Card Feedback Comment cards are available at St Clare Hospice and in the St Clare Hospice retail shops. As with the User Feedback Questionnaires, the feedback from the comment cards is used to help improve services provided by St Clare Hospice. Feedback relating to compliments and complaints is shared with the management team at the hospiceâ&#x20AC;&#x2122;s risk management meeting. This is in turn shared with wider team members and the Board of Trustees through the governance structure.
User Involvement Forum The Forum is lead by the Director of Patient Care and is made up of members of the public who have received care or who are currently receiving care from St Clare Hospice. Meetings are held every two months with the group being very active and supportive in all areas of Hospice development. The ultimate aim is to always improve Hospice services using valuable feedback and the experience of service users.
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Statements from External Stakeholders
NHS West Essex CCG “West Essex Clinical Commissioning Group is pleased to endorse the contents of this Quality Account for NHS care at St Clare Hospice. As one of the commissioning organisations for St Clare Hospice, we have been involved in reviewing the content of this Quality Account, ensuring that it reflects accurately the quality, safety and effectiveness of services provided. St Clare Hospice has also consulted with patient and public groups, staff and statutory bodies, taking into account their opinions. The priorities and performance illustrated within the account for this year and last year accurately reflect and support both national and local priorities. West Essex Clinical Commissioning Group is pleased to endorse the publication of this account.”
NHS Hertfordshire “During 2012/3, St Clare Hospice has continued to provide a high quality and much valued service to the population covered within Hertfordshire border. Their inpatient service continues to be an invaluable resource and the Hospice has contributed positively to the development of end of life and palliative care services during the past year. 2013/4 presents new demands for all Hospices: As well as establishing its compliance with NICE guidelines, the Hospice will be responding to a more comprehensive review of the service against agreed performance metrics and responding to the challenges of adapting to the new environment of clinical commissioning groups. The Hospice’s positive and enthusiastic support for these initiatives and willingness to be a partner for improvement will benefit those who need the general and specialised care and support services that the Hospice offers.”
Healthwatch, Essex “We recognise that Quality Account reports are a useful tool in ensuring that NHS healthcare providers are accountable to patients and the public about the quality of service they provide. We fully support these reports as a means for providers to
49
review their services in an open and honest manner, acknowledging where services are working well and where there is room for improvement. We welcome the opportunity to provide a patient and public perspective on the Quality Accounts. As a newly-established organisation (we took on statutory responsibility on 1st April 2013), we are not in a position to comment retrospectively on the findings of the past year. We will, however, cooperate fully in the future production of these reports. We are an organisation which intends to provide comment rooted in evidence – be it ‘soft’ intelligence or more extensive, quantitative data. Following the Francis Report, we believe there is a significant challenge and opportunity for the whole health and social care system to look at how evidence relating to patient experience can be set on an equal footing with standard NHS data about performance and quality. We look forward to working together in the production of Quality Accounts in the coming year and making sure that the voice and experience of patients and the public form an integral part of these documents. At a time when the NHS is facing great change and financial challenge, patient experience and quality of care are more important than ever, and we welcome the opportunity to help shape the NHS of the 21st century.”
How to provide feedback to St Clare Hospice on this report or any of our services
We would like to encourage you to contact us with questions, comments or suggestions following reading this report or from your experience of St Clare Hospice. Contact details can be found on the back cover of this report or you can write to:
Tanya Curry Chief Executive Officer St Clare Hospice, Hastingwood Road, Hastingwood CM17 9JX or email:tanya.curry@stclarehospice.org.uk
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